Basic Information
| Provider Information | |||||||||
| NPI: | 1023187390 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARTELL | ||||||||
| FirstName: | KATHERINE | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 518 | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302370518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7706318277 | ||||||||
| FaxNumber: | 7706319403 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 ATHENS HWY | ||||||||
| Address2: | |||||||||
| City: | LOGANVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300522277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705542307 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | GA007175 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | GA007175 | 01 | GA | STATE LISC NUMBER | OTHER |